Abstract

Purpose: The aim of this study was to investigate whether patients with schizophrenia in Germany differ in the number and frequency of medical screenings in primary care compared to healthy controls and whether such screenings are provided to schizophrenic patients by general practitioners (GPs) or psychiatrists. Methods: In a self-report and questionnaire-based cohort study we quantified the screenings for cardiovascular risks and somatic comorbidity. We examined 81 patients with an ICD- 10 F2 diagnosis (n=56 inpatients and n=25 outpatients) and 67 controls. Results: GPs were the initiators of significantly more screening assessments in the control group compared to the patients´ cohort. Controls were more often asked about their smoking habits and they significantly more often consulted medical specialists other than a GP or a psychiatrist. On the other hand, schizophrenic patients had undergone EEG or brain imaging procedures significantly more often than controls. Vaccination against tetanus appeared to be neglected in patients with schizophrenia. Conclusion: Adjustments in the German health care system are necessary to address the issues of medical screening in patients with schizophrenia and related disorders, thus bridging the gap between mental and physical health.

Keywords

Introduction

Patients with schizophrenia and related disorders experience
a markedly shorter life expectancy than the general population.
Although this difference has often been attributed to suicide,
cardiovascular disease is in fact the leading cause of death
(up to 75%) for patients with these disorders [1]. Risk factors
for cardiovascular disease include obesity, dyslipidaemia, hypertension, diabetes mellitus and cigarette smoking. All
of these risk factors are highly prevalent in patients with
schizophrenia and related disorders [2-4]. With the widespread
use of second generation antipsychotic agents known to produce
adverse metabolic effects [5], concern about medical morbidity
has intensified, particularly with respect to cardiovascular
sequelae [4,6].

Such concerns prompted the European Psychiatric
Association (EPA), supported by the European Association
for the Study of Diabetes (EASD) and the European Society
of Cardiology (ESC), to develop and publish a consensus
paper in order to ensure that patients with schizophrenia and
related disorders are screened for risk factors of cardiovascular
disease [7]. However, apparently these and other guidelines are
not routinely implemented in the clinical care of patients [8- 10]. This suggests that screening for cardiovascular morbidity
in these patients needs to be optimised. The identification of
cardiovascular risks is often hindered by barriers related to
patients´ neglectful health care utilisation behaviours (due
to symptoms like anxiety, social withdrawal or cognitive impairment). On the other hand, the responsibility of specific
substructures of the health care system (general practitioners and
psychiatrists) to address somatic comorbidity is much debated
at present. Although thorough primary screening efforts are
crucial in patients with schizophrenia and related disorders, in
some countries there is a paucity of funding for general somatic
care for patients with severe mental disorders, especially those
in long-term psychiatric treatment [11].

Several studies have confirmed a higher prevalence for
cardiovascular morbidities in patients with schizophrenia
and related disorders compared to control populations,
but, up to now, epidemiologic studies in Germany dealing
with deficiencies in patient’s screenings (before the actual
manifestation of clinically relevant conditions) are missing
[12]. Such data are needed, in order to propose system changes
that will improve the general medical care for patients with
schizophrenia and related disorders in Germany. In the present
cross-sectional cohort study we quantified medical health
care utilisation behaviour, screenings for cardiovascular risks
and other commonly enquired parameters in primary care, as
well as a series of other mental health associated aspects in
self-report questionnaires. This was done in patients suffering
from schizophrenia (in- and out-patients), as well as a cohort
of healthy controls without history of a psychiatric disorder.
The aim of the study was to investigate in a retrospective
self-report and questionnaire-based manner, whether patients
with schizophrenia and related disorders in Germany differ
in the number and frequency of screenings for cardiovascular risk factors in primary care compared to a control group and
whether such screenings are provided to schizophrenic patients
by general practitioners (GPs) or psychiatrists. In addition,
the participation in other primary care procedures, such as
cancer prevention programs (bowel cancer, breast cancer) and
vaccination programs (tetanus) was part of our study protocol.

Methods

Patients and controls

Inclusion criteria for schizophrenic patients were: an F2
diagnosis according to ICD-10, a minimum of one visit to an
outpatient psychiatrist within the past six months and an age
between 18 and 80 years. Exclusion criteria were: presence of
a legal guardian, language barriers and inability to participate
or fill in questionnaires. Inpatients were recruited during
their hospital stay in the psychiatric university clinic (Central
Institute of Mental Health, Mannheim, Germany) due to an
acute exacerbation of schizophrenia. Outpatients were stable
patients with schizophrenia recruited during routine visits in
the ambulatory “Zentrum für Nervenheilkunde”, Mannheim,
Germany, an outpatient medical center employing solely
psychiatrists and neurologists. Control subjects were aged
between 18 und 80 years; any past or current psychiatric disorder
led to their exclusion from the study. All study participants
signed an informed consent. The study was approved by the
ethics committee of the Faculty of Medicine Mannheim,
University of Heidelberg, Germany.

General medical history (self-reports)

All study participants were asked in a short interview to
provide information about their general medical history by
answering questions in a questionnaire that we had specifically
constructed for this purpose. Questions asked regarded the
medical health care utilization behavior (frequency and
intervals of visiting a GP, a psychiatrist and other specialists),
eating patterns and physical activities, medication regimens,
adherence to medication, as well as the use of nicotine or other
psychotropic substances.

Patients with schizophrenia were additionally asked about
their psychiatric history, prior suicide attempts, last time and
total number of hospital stays due to schizophrenia; patients
also had to declare whether a GP or a psychiatrist had made the
diagnosis of schizophrenia first.

In order to evaluate somatic comorbidity, all participants
were interviewed according to the “Cumulative Illness Rating
Scale” (=CIRS) [13].

Subjective well-being/mental health status
(questionnaires)

In addition, study participants had to fill in questionnaires for
the assessment of various outcome parameters mostly associated
with mental health. The applied questionnaires included the
“Short Form Health Survey” (SF-12), consisting of physical and
mental component summary scales for the assessment of health
associated quality of life [14], the “Patient Health Questionnaire-Depression” (PHQ-D), an instrument to assess depressive
symptoms [15], the “Mannheim Polytox-Evaluation” (MAPE)
for the assessment of substance use (alcohol, illegal drugs or
medication) [16], the “Pearlin sense of mastery scale” for selfefficacy
and the German short questionnaire of burden (KFB) as
the short form of the “Daily Hassles Scale” for the identification
of stress factors [17,18].

All participants of the study were also asked to fill in the
“Medical Interview Satisfaction Scale” (MISS) as a measure of
satisfaction with their GP and psychiatrist [19].

Quality of provided medical care (sum score)

In order to estimate the adequacy of medical care provided
by GPs or psychiatrists, we asked all study participants to
answer whether they had received one or more of the following:
1. ECG during the last 12 weeks, 2. Physical examination during
the last 12 weeks, 3. Monitoring of blood pressure during the
last 12 weeks, 4. Blood sampling, 5. Assessment of smoking
habits, 6. Assessment of family history with regard to physical
or psychiatric conditions, 7. Assessment of weight and height
(BMI), 8. Cancer screening procedures within the last year, and
9. Vaccination against tetanus within the past 10 years.

Each of these items counted equally to sum a maximum of
nine points. At the same time we assessed whether it had been
the GP or the psychiatrist that had prompted the assessment.
In the case that both the GP and the psychiatrist had initiated
an assessment, a point was assigned to both. Items marked as
“never received” or “I do not know” were not counted.

The items mentioned above were selected according to the
recommendations of international associations with regard
to necessary medical care screenings and according to the
recommendations of the German health insurance with regard
to the performance of preventive check-up examinations [6,20].

Statistics

Normal distribution of data was analysed with the
Kolmogorov-Smirnov test. The statistical analysis plan included
descriptive analyses followed by comparisons of schizophrenic
patients and controls, as well as inpatients vs. outpatients
by means of student’s t-test or Mann-Whitney U-test, as
appropriate. All statistics were carried out using PASW 18.

Results

Cohort description and socio demographic data

81 schizophrenic patients were included (25 outpatients and
56 inpatients). The control group consisted of 67 participants.
Of the controls, n=35 (52.2%) were male and n=32 (47.8%)
were female. Of the schizophrenic patients, n=57 (70.4%) were
males and n=24 (29.6%) females (p=0.02). The control group
was significantly younger than the patient’s group (n=67, 35.3
± 13.2 yrs. vs. n=81, 41.4 ± 12.3 years, respectively; p=0.01).
Since the power was not sufficient to perform an analysis of
variance, we ruled out a systematic error caused by the above
mentioned age difference by performing a second analysis of the investigated parameters with the core age group from 21-50
years, where 80% of the controls and 74% of the schizophrenic
patients belonged to. The results were comparable and did not
differ significantly from the results presented below. Thus, we
confer comparability of study and control group.

Controls and patients differed significantly in certain sociodemographic
aspects: 21% of patients were living in a patients´
facility (vs. 0% of the controls, p<0.01), 24.7% of patients were
unemployed or received pension (vs. 10.3% of the controls,
p=0.02), while 21% of patients had no professional training
(vs. 7.7% of the controls, p=0.04). With regard to marital
status, 70.4% of the patients were single (vs. 53.7% of controls,
p<0.01).

There were no significant differences between patients and
controls with regard to the presence of a GP or the reasons for
their lacking, the total years of consultation, the time of last
consultation or the frequency of consultations. According to
the MISS, patients and controls were similarly satisfied with their GP (p=0.40) (Table 1). When comparing inpatients and
outpatients, outpatients seemed to be significantly more content
with their GP than inpatients (n=24, 70.2 ± 8.9 vs. n=50, 61.6 ±
10.7; p<0.01).

Variable

n

Controls

n

Patients

T

df

p-value

Last consultation (weeks)

64

30.1 ± 54.7

73

39.8 ± 85.7

0.8

124.0

0.43

Frequency of GP consultations (per year)

63

3.7 ± 6.1

74

5.1 ± 7.7

1.3

134.3

0.21

MISS – Satisfaction with GP

64

65.8 ± 9.7

74

64.4 ± 10.9

-0.8

135.9

0.40

Last physical examination (weeks)

63

70.2 ± 111.7

53

59.1 ± 103.4

-0.6

112.9

0.58

Last ECG (weeks)

45

145.7 ± 163.7

37

84.7 ± 127. 6

-1.9

79.8

0.06

Last blood pressure assessment (weeks)

63

47.4 ± 96.3

43

42.8 ± 83.1

-0.3

98.3

0.78

Last blood drawn (weeks)

62

87.4 ± 131.0

49

42.1 ± 131.7

-1.8

102.9

0.07

Last cancer prevention (years)

28

6.2 ± 19.4

23

2.0 ± 3.3

-1.1

28.9

0.28

Last assessment of height and weight (weeks)

50

106.9 ± 151. 6

37

76.0 ± 225.8

-0.7

59.2

0.47

Vaccination against tetanus during the past 10 years?

52

78.8%

43

53.1%

10.5

1

<0.01

History of smoking ever assessed?

60

89.6%

60

74.1%

5.7

1

0.02

Family history ever assessed?

35

52.2%

63

77.8%

12.1

1

<0.01

GP score (median)

67

3.2 ± 1.9

81

2.0 ± 1.6

3.8

129.1

<0.01

Ever carried out?

EEG

11

16.4%

72

88.9%

78.2

1

<0.01

CCT

9

13.4%

36

44.4%

16.7

1

<0.01

Cerebral MRI

15

22.4%

41

50.6%

12.4

1

<0.01

Number of specialists consulted during the last 2 years (GP and psychiatrist excluded)

67

2.8 ± 1.5

80

1.8 ± 1.6

-3.7

144.2

<0.01

Table 1: Health care use of participants.

Psychiatric history

Almost half of all patients (48.1%) were diagnosed with
schizophrenia by a hospital psychiatrist. Almost a third of
diagnoses (29.6%) were made in a psychiatric outpatient
setting. A GP was responsible for diagnosis in 12.3% of these
cases. The time of first diagnosis had been 13.5 (± 10.2) years
ago. At the time of our investigation, patients had had an
average of 5.6 hospital admissions; with the last admission 4.2
years ago (the ongoing admission of schizophrenic inpatients
was not considered). The outpatients had been diagnosed with
schizophrenia long before the inpatients (p=0.02) and their last
hospital stay due to schizophrenia dated back longer (p=0.04).
The total number of hospital admissions did not differ between
in- and outpatients (n.s.). A total of 37.5% patients reported
having attempted suicide at some point of their lives.

Interestingly, outpatients were significantly more content
with their psychiatrists than inpatients according to the MISS
(p<0.01).

History of medical care

We found significant differences between patients and
controls regarding EEG, cerebral CT or MRI procedures,
with schizophrenic patients having undergone each of these
procedures significantly more often than controls (p<0.01,
respectively) (Table 1). On the other hand, controls reported to
have consulted a specialist (other than the GP or a psychiatrist)
significantly more often during the past two years than
schizophrenic patients did (p<0.01) (Table 1). Patients´ intake
of medicine on a daily basis was significantly higher compared
to control subjects (p<0.01).

Nicotine consumption in pack years was approx. 3 times
higher in the schizophrenic group (p<0.01), that also reported
to have less control over eating behaviors (p=0.03), while being
significantly less active (p=0.02) (Table 2). In addition, patients
with schizophrenia had a significantly higher BMI compared to
controls (n=81, 27.8 ± 5.0 vs. n=65, 25.3 ± 4.1 kg/m2; p<0.01)
(Table 2).

Variable

n

Controls

n

Patients

T

df

p-value

Hours of physical activity per week

66

8.3 ± 8.4

81

4.7 ± 10.3

-2.3

145.0

0.02

Smoker

27

40.9%

48

59.3%

4.9

1

0.02

Pack years

66

5.0 ± 8.3

81

14.5 ± 17.6

4.3

118.9

<0.01

Actual weight change (kg)

67

+0.5 ± 3.5

81

+1.3 ± 7.8

0.7

115.8

0.46

BMI (kg/m2 )

65

25.3 ± 4.1

81

27.8 ± 5.0

3.4

144.0

<0.01

SF-12 total

67

40.3 ± 5.0

81

31.3 ± 7.1

-9.1

142.8

<0.01

SF-12 physical

67

17.6 ± 2.3

81

14.4 ± 3.3

-6.9

143.0

<0.01

SF-12 mental

67

22,7 ± 3,3

81

16.8 ± 4.5

-9.1

144.2

<0.01

PHQ-D

67

3.0 ± 3.1

81

9.6 ± 5.7

9.0

127.9

<0.01

MAPE alcohol

67

7.2 ± 3.4

81

5.1 ± 3.0

-4.1

133.7

<0.01

MAPE prescribed drugs

67

2.2 ± 2.6

81

5.1 ± 4.6

4.8

130.1

<0.01

MAPE illegal drugs

67

0.8 ± 2.9

80

1.3 ± 2.7

1.2

136.4

0.23

Pearlin – self-efficacy

67

17.6 ± 2.3

81

12.9 ± 3.5

-9.7

140.4

<0.01

KFB – stress factors

67

36.4 ± 10.7

81

50.6 ± 13.1

7.2

146.0

<0.01

CIRS

67

2.0 ± 2.8

81

4.7 ± 2.2

6.2

124.3

<0.01

Table 2: Health status of participants.

Similar results were observed when we compared the
group of controls separately against the group of inpatients and
outpatients (data not shown).

When comparing inpatients against outpatients we found that
inpatients underwent a cerebral MR examination significantly
more often than outpatients (p<0.01), while all other results did
not differ between the groups (data not shown).

Subjective well-being/mental health status
questionnaires

We found significant differences between patients and
controls in all investigated domains of mental health and wellbeing:

In the SF-12, schizophrenic patients have systematically
scored lower than controls (p<0.01) in all domains, (Table 2),
indicating that patients with schizophrenia considered their
quality of life - in association with their physical and mental
health status- to be lower than that of control subjects.

In the PHQ-D, schizophrenic patients obtained more than
the threefold scores compared to the group of controls (p<0.01),
indicating a significantly higher presence of depressive
symptoms (Table 2).

In the MAPE, we found that controls reported a significantly
higher alcohol consumption than patients (p<0.01), while
patients stated to have a higher intake of prescribed drugs than
controls (p<0.01) (Table 2).

Moreover, according to the Pearlin scale, schizophrenic
patients estimated their self-efficacy significantly lower than
controls (p<0.01) and evaluated their daily life stress situations
(KFB) significantly higher than did the group of controls
(p<0.01) (Table 2).

In the CIRS, schizophrenic patients exhibited a higher
multimorbidity and severity of physical illness than controls
(p<0.01) (Table 2).

The general adherence to medication regimes was similar in
both groups (p=0.13).

When comparing the group of inpatients against the group of
outpatients, we found that inpatients scored significantly lower
in the mental domain of the SF-12 (n=56, 15.9 ± 4.4 vs. n=25,
19.0 ± 4.2; p<0.01) and in the total score (n=56, 29.8 ± 6.8 vs.
n=25, 34.4 ± 6.7; p=0.01). Inpatients also reached higher scores
in the KFB (identification of stress factors) (n=56, 52.9 ± 12.5
vs. n=25, 45.3 ± 13.1; p=0.02). The groups did not differ in all
other applied questionnaires (data not shown).

Quality of provided medical care (sum score)

We found that the GP performed significantly more
assessments in the group of controls than in the group of patients
(3.2 ± 1.9 vs. 2.0 ± 1.6 points; p<0.01).

When taking a closer look at each of the items separately,
we observed that schizophrenic patients were more often asked
about their family history than controls (p<0.01) (Table 1).
However, controls were apparently more often asked about their
smoking habits (p=0.02) (Table 1). Controls had also received vaccination against tetanus significantly more often than the
group of schizophrenic patients (p<0.01) (Table 1).

There were no significant differences when comparing the
group of inpatients against the outpatients, with the exception
of inpatients having been asked about their smoking habits
significantly more often than outpatients (p=0.01) (data not
shown).

As far as the health status assessments were concerned, we
found that psychiatrists initiated such significantly more often
in the case of inpatients compared to outpatients (p=0.04) (Table
3).

Discussion

Cardiovascular disease is the leading cause of morbidity and
mortality in patients with schizophrenia and related disorders.
This is due to the fact that risk factors for cardiovascular disease,
including obesity, dyslipidaemia, hypertension, diabetes
mellitus and cigarette smoking- are all highly prevalent in this
group of patients. With the widespread use of second generation
antipsychotic agents, the concern about cardiovascular sequelae
has intensified [21]. However, several investigations suggest
that cardiovascular morbidity in patients with schizophrenia
and related disorders is screened for less efficiently than in
individuals from the general population [22-25].

We hypothesised that patients with schizophrenia in
Germany receive less screenings for physical health conditions,
especially cardiovascular-related parameters, than controls.
In the present retrospective, self-report- and questionnairebased
study we assessed aspects of general and cardiovascular
medical history, mental health status and subjective well-being
in a cohort of schizophrenic patients and randomly selected
controls. In addition, based on published recommendations, we
assessed a self-constructed sum score consisting of 9 items with
regard to routine screening procedures (e.g. blood sampling,
measures of BMI, etc.), cancer prevention examinations and
status of vaccination against tetanus, in order to evaluate the
quality of the provided medical care.

In summary, we found that compared to controls, patients
suffering from schizophrenia showed adverse outcomes in a
number of parameters (e.g. higher nicotine consumption, higher
depression scores, somatic multimorbidity, less subjective selfefficacy,
less health related quality of life, etc.). In some of these
parameters inpatients had worse outcomes than outpatients.
These results are not surprising and have been repeatedly
confirmed in studies [7,26-29]. Being older and at higher
medical risk, one would expect medical care and examinations
to be more frequent and extensive in the schizophrenic study
group, compared to the younger control group.

Interestingly, vaccination against tetanus seems to be a neglected issue in patients with schizophrenia. GPs were the
initiators of more screening assessments in the case of the control
group over the patient’s cohort. Controls were more often asked
about their smoking habits than patients and smoking habits were
significantly more often assessed in inpatients than outpatients.
Controls reported significantly more often than schizophrenic
patients to have consulted medical specialists other than a GP
or a psychiatrist. On the other hand, schizophrenic patients have
reported to have undergone EEG or brain imaging procedures
significantly more often than controls. By comparing the sum
score, the number of screenings initiated by psychiatrists
differed significantly between inpatients and outpatients with
schizophrenia. The monitoring in the outpatient group is mostly
done by the GP (GP sum score), the inpatient group gets more
service from the psychiatrist (psychiatrist score). The outpatient
group is more content with their doctors. Thus, severity of
illness seems to be a factor determining medical service and its
quality.

Patients with schizophrenia and related disorders have
a relative risk for cardiovascular disease between 1.5 to 2.0
compared to the general population [30]. Roberts et al. reviewed
case notes of 195 schizophrenia patients and 390 matched controls
and found that patients with schizophrenia were significantly
less likely to have had their blood pressure or cholesterol levels
recorded [31]. Oud et al. conducted a search of the MEDLINE,
EMBASE and PsycINFO data-bases and the Cochrane Library
and demonstrated that the incidence in the primary care setting of a wide range of diseases, such as diabetes mellitus,
the metabolic syndrome, coronary heart diseases and chronic
obstructive pulmonary disease (COPD) is significantly higher
in schizophrenia patients than in the general population [32].
The UNITE global survey; a 3 month internet-based initiative
that recruited schizophrenic patients and caregivers from 11
countries (incl. Germany) clearly demonstrated that patients
received guideline-discordant care [33]. Cardiovascular factors
were found to be underdiagnosed in schizophrenic patients also
in Spain and to lead to frequent hospitalisations associated with
a substantial in-hospital mortality [34,35]. Other studies could
demonstrate that patients are less likely than non-schizophrenic
individuals to receive cancer screening [36].

Overall, our results presented here indicate that, although
there are possibilities for optimisation, the physical medical
care of patients with schizophrenia is not as detrimental as
hypothesised in the first place. However, this might be the
case in an urban environment (Mannheim, Germany), but
may be substantially different in rural areas; this remains to be
investigated. Further research is needed to verify our results
about the possible association of severity of mental illness and
medical examinations.

Our study was conducted retrospectively with all disadvantages and weaknesses that such a type of study may
have. In addition, data might be biased as not all schizophrenic
patients were cooperative or able to fill in the questionnaires
due to their psychiatric condition. Another bias may be that
general medical history and mental health status domains were
assessed based on self-reports and questionnaires. A possible
way to increase validity of the gathered data would have been
to -at least for a certain number of patients- confirm patients´
statements by comparing them to patient’s files. After all,
we have not gathered laboratory/metabolic parameters (e.g.
blood lipids, blood pressure, etc.), in order to be able to make
statements regarding the patients´ actual physical medical
condition compared to controls.

Published guidelines aim at increasing the awareness of the
general medical needs of patients with schizophrenia. However,
none of the current guidelines gives a clear suggestion whether
psychiatrists or GPs should provide the necessary medical
care for patients with schizophrenia [37-42]. The current
debate on duties within the German health care system also
tackles the question of who might be responsible and able to
provide screening for cardiovascular risks to patients with
schizophrenia and related disorders. The key points seem to be
who is compiling the monitoring plan, who is undertaking the
monitoring or who is controlling that the monitoring is done
(GP or psychiatrist). In Germany, the GP is mainly responsible
for preventive examinations and the coordination of health
care (referral to other medical specialists). On the other hand,
psychiatrists are the experts in antipsychotic drugs, their side
effects and obligatory monitoring; however, psychiatrists cannot
bill certain physical screenings with the health insurances
[43]. We suggest that the communication between GPs and
psychiatrists be optimized. Monitoring plan and control should
be in the responsibility of the psychiatrist, while implementation
of monitoring should be done by the GP.

Conclusion

Our results may help to operate the necessary adjustments
in the health care system to address the issues of screening for cardiovascular risk factors and somatic comorbidity in patients
with schizophrenia and related disorders, thus bridging the gap
between mental and physical health [44]. The reintegration of
psychiatry and classical somatic medicine, enhanced models
of shared care with an ultimate goal of providing high quality
multidisciplinary services to a vulnerable patient population,
represents the most important challenge for psychiatry and
general health care today, requiring urgent and comprehensive
action towards achieving an optimal solution.